Claims Over Mental Health Parity Benefits Can Proceed.


The U.S. District Court for the Eastern District of New York grants in part and denies in part the defendants' motion to dismiss the plaintiffs' claims of violation under the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and the Employee Retirement Income Security Act of 1974 (ERISA).

The plaintiffs include a participant in a large employer group health insurance plan and her husband, who is a beneficiary of the plan. The defendants are the health insurance companies that issued, administered and insured the plan.

Since 2015, the plaintiff participant has been treated for an eating disorder. She received individual counseling from a psychologist and family counseling from a licensed clinical social worker who has completed postgraduate training. The plaintiff participant's husband has been treated by a different psychologist and used the same social worker for family counseling. The psychologists and the social worker are out-of-network providers and therefore do not have a contract with the defendants for in-network rates.

The plaintiff participant and her husband submitted claims for their treatment from the psychologists and the social worker, and the defendants issued benefit payments pursuant to the plan. The plan provides that out-of-network benefits are determined based on an allowed amount, which is the maximum amount a provider's bill is deemed eligible for reimbursement. The allowed amount for mental health services provided by psychologists and masters-level counselors, in contrast with counseling services provided by physicians, is reduced by 25% to 30% under the plan. As a result, the plaintiff and her husband pay more money for psychotherapy and family counseling services from out-of-network nonpsychiatrists.

The plaintiffs filed suit against the defendants, alleging claims for recovery of benefits under the plan, enforcement of the plaintiff participant's rights under the plan, and clarification of her rights to future benefits under MHPAEA and ERISA.

First, the defendants moved to dismiss all claims against certain of the defendants, arguing that they are not the proper entities to be defendants for ERISA claims. For a recovery-of-benefits claim under ERISA Section 502(a)(1)(B), only the plan and the administrators and trustees of the plan in their capacity as such may be held liable. If a plan specifically designates a plan administrator, then that individual or entity is the plan administrator for purposes...

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